Incident investigation·March 26, 2026

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit, and met with Administrator, Rabah Sbaitan, and Health Services Director, Felicidad Ybona, and Regional Care Director, Ticarra Boyd. The purpose of the visit was to follow up on self-reported incident reports submitted to Community Care Licensing. Incident Report 1: The Santa Rosa Regional Office (SRRO) received a report on 12/23/2025. Report stated that on 12/21/2025, Resident 1 (R1) exited the facility through the egress doors after pulling the emergency alarm. Facility implemented their elopement protocols and notified San Rafael Police Department (SRPD). R1 was found three blocks from the facility by SRPD. Facility made all appropriate notifications per regulation. Review of R1's file showed that they are unable to leave the facility unsupervised or without an escort per their Physician Report dated 11/14/2025 and Care Plan. Facility conducted elopement training on 12/24/2025. Deficiency issued today has been cleared and Plan of Corrections Letter provided during visit. Incident Report 2: The SRRO received a report on 03/17/2026. Report stated that on 02/17/2026, Resident 2 (R2) was evaluated by a wound specialist. Additional information provided to the Department revealed that on 02/17/2026, the wound specialist believed that R2's wound could be unstageable but further testing would be needed to confirm. On 03/17/2026, the wound specialist conducted additional tests where it was determined that R2's wound was a Stage 2 pressure ulcer. Continued on LIC809C Continued from LIC809 Department did not receive an exception to retain a resident with a prohibited condition once it was believed that R2 could have had an unstageable wound in February 2026. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, Appeal Rights, and Plan of Corrections Letter discussed and provided to Administrator. Signature on form confirms receipt of documents.